Blue Cross Blue Shield and Blue Care Network Preferred ...
Blue Cross Blue Shield and Blue Care Network Preferred Alternatives -- November 2021
The Blue Cross and BCN Preferred Alternatives list is a helpful guide when selecting alternative prescription drugs. This list is intended as a reference guide and doesn't dictate coverage. Some Blue Cross and BCN members don't have coverage for tier 3 (non-preferred) agents, or the suggested alternatives. The brand (trade) names for the preferred alternatives are listed for reference. The generic equivalent will be dispensed when the member fills a prescription. The brand may not be covered or may require a higher copay. Prior approval or step therapy may be required for tier 3 drugs or preferred alternatives.
Members should refer to their specific drug benefit information at pharmacy for a full list of covered drugs and requirements.
Tier 3
Preferred alternatives
ACCRUFER
OTC iron supplements
ACIPHEX SPRINKLE Aciphex, Nexium, Prevacid, Prilosec, Protonix
ACTHAR H.P.
Sabril (for infantile spasms only)
ACUVAIL
Acular, Bromday, Ocufen, Voltaren ophthalmic
ADZENYS XR-ODT; AMPHETAMINE 1.25MG/ML SUSPENSION (AUTHORIZED GENERIC OF ADZENYS ER)
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
AEMCOLO
Bactrim DS, Cipro, Vibramycin, Zithromax
AFREZZA
Fiasp (all forms), Novolin (NDCs ending in 00, 01, 11, and 15), Novolog (all forms)
AKYNZEO
Emend plus Zofran/ODT or Kytril
ALKINDI SPRINKLE generic hydrocortisone tablets (Cortef)
ALOCRIL
Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol
ALOMIDE
Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol
ALTRENO
Retin-A
AMZEEQ
Minocin, Monodox, tetracycline, Vibramycin
ANGELIQ
Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot
APTIOM
Dilantin, Gabitril, Keppra/XR, Lamictal, Lyrica, Mysoline, Neurontin, Tegretol, Topamax, Trileptal, Vimpat, Zonegran
ARAKODA
Aralen, Lariam, Malarone, Monodox, Primaquine, Vibramycin
ARANESP
Procrit, Retacrit
Tier 3
ARMOUR THYROID ASTAGRAF XL AUBAGIO AURYXIA AZASAN AZASITE
AZELEX AZSTARYS
BAFIERTAM BALCOLTRA
BASAGLAR KWIKPEN U-100 BAXDELA BECONASE AQ BELSOMRA BESIVANCE
BETASERON
Preferred alternatives
NP Thyroid, Westhroid
Prograf capsules
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
OTC Tums, Phoslo, Renagel, Renvela
Imuran
Bacitracin, Bleph-10, Ciloxan, Moxeza, Ocuflox, Polysporin, Polytrim, Quixin, Tobrex, Vigamox, Zymaxid
Benzaclin, Benzamycin, Differin, Duac, Epiduo , Retin-A, Tazorac
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
Generic monophasic contraceptives with iron (Femcon Fe, Generess Fe, Loestrin Fe, Loestrin 24 Fe, Minastrin 24 Fe, etc.)
Lantus (all forms), Levemir (all forms), Toujeo (all forms), Tresiba Flextouch
Avelox, Cipro/XR, Floxin, Levaquin, Zyvox
Astelin, Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase
Ambien/CR, Desyrel, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata
Bacitracin, Bleph-10, Ciloxan, Moxeza, Ocuflox, Polysporin, Polytrim, Quixin, Tobrex, Vigamox, Zymaxid
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
BEVESPI AEROSPHERE
BIJUVA
BINOSTO BONJESTA
BRIVIACT
BRONCHITOL BRYHALI
BUNAVAIL CAPLYTA
CARDURA XL
CAROSPIR CAYSTON CELONTIN
CEQUA CHENODAL CHORIONIC GONADOTROPIN CIPRO HC
CLARINEX-D
CLENPIQ
CLEOCIN VAGINAL OVULES CLIMARA PRO
CLINDESSE COMBIGAN COMBIPATCH
CONTRAVE
CORTIFOAM
Preferred alternatives
Combination products: Anoro Ellipta, Breztri Aerosphere, Incruse Ellipta, Stiolto Respimat, Trelegy Ellipta Single ingredient products: Serevent Diskus, Spiriva/Respimat
Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot
Actonel, Atelvia, Boniva, Fosamax
OTC doxylamine plus OTC vitamin B6, Kytril, Zofran/ODT
Depakote/ER, Keppra/XR, Lamictal/ODT, Neurontin, Tegretol, Topamax, Trileptal
generic sodium chloride inhalation 3%, 7%
Clobevate, Clobex, Diprolene gel, ointment; Olux/-E, Ultravate cream, ointment
Suboxone
Abilify, Clozaril, Geodon, Invega, Risperal, Seroquel/XR, Zyprexa
Avodart, Cardura, Flomax, Hytrin, Jalyn, Proscar, Rapaflo, Uroxatral
Aldactone
Tobi
Diamox, Klonopin, Onfi, Topamax, Zarontin
Lacrisert, Restasis, Xiidra
Actigall, Urso/Forte
Ovidrel, Pregnyl
ciprofloxacin 0.2% dropperette, Ciprodex, Cortisporin, Floxin otic, Otovel
Clarinex, Histex PD, OTC Claritin**, OTC Zyrtec**, Xyzal
Colyte, Golytely, Moviprep, Nulytely, PegPrep
Cleocin vaginal cream, Metrogel-Vaginal
Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot
Cleocin vaginal cream, Metrogel-vaginal
Alphagan plus Timoptic
Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Minivelle, Vagifem, Vivelle-Dot
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
Canasa, Cortenema, Proctocort suppository, Proctosol-HC suppository, Rowasa, SfRowasa
Tier 3
CYCLOSET
CYSTADROPS DAYTRANA
DAYVIGO DESVENLAFAXINE ER DEXILANT DIACOMIT DIFICID DIPENTUM DIVIGEL DORYX MPC DUAVEE DUOBRII DUPIXENT
DUTOPROL DYANAVEL XR
ECOZA EDARBI EDARBYCLOR EDEX
Preferred alternatives
Actos, Glucophage, a DPP-4 inhibitor (Januvia, Tradjenta), an SGLT-2 inhibitor (Farxiga, Invokana, Invokamet, Jardiance), a sulfonylurea (Amaryl, Glucotrol/XL, Glynase)
Cystaran
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Ambien/CR, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL
Aciphex, Nexium, Prevacid, Prilosec, Protonix
Depakote, Onfi, Topamax
Flagyl, Vancocin
Apriso, Asacol HD, Azulfidine/En-Tab, Canasa, Colazal, Delzicol, Lialda, Pentasa
Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot
Minocin, Monodox, tetracycline, Vibramycin
Brisdelle, Climara, Estrace or Premarin plus a progestin; Effexor/XR
Ultravate cream/ointment plus Tazorac
For asthma: Advair, Dulera, Symbicort For atopic dermatitis: Cellcept, generic topical steroids, Gengraf/Neoral, Elidel, Imuran, methotrexate, Protopic For chronic rhinosinusitis with nasal polyposis: Flonase; Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort
Toprol XL plus hydrochlorothiazide
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Diflucan, Lamisil, Nizoral, OTC Clotrimazole, OTC Miconazole, Spectazole, Sporanox
Atacand/HCT, Avalide, Avapro, Benicar/HCT, Cozaar, Diovan/HCT, Exforge, Hyzaar, Micardis/HCT
Atacand HCT, Avalide, Benicar HCT, Diovan/HCT, Hyzaar, Micardis HCT
Caverject, Cialis, Levitra, Muse, Staxyn, Viagra
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
EDLUAR
ELEPSIA XR ELESTRIN
ELIXOPHYLLIN EMFLAZA EMSAM
EMVERM ENDARI ENDOMETRIN ENSTILAR
ENVARSUS XR EPIDIOLEX EPIDUO FORTE
EPOGEN EQUETRO
ERTACZO EUCRISA EVAMIST
EXELDERM, SULCONAZOLE NITRATE 1% CREAM AND SOLUTION (AUTHORIZED GENERIC OF EXELDERM) EXSERVAN EXTAVIA
FABIOR, TAZAROTENE 0.1% FOAM (AUTHORIZED GENERIC OF FABIOR) FACTIVE
FANAPT
FEMRING
Preferred alternatives
Ambien/CR, Intermezzo, Lunesta, Restoril, Rozerem, Silenor, Sonata Keppra/XR Alora, Climara, Estrace, Estring, Estrogel, Vagifem, Vivelle-Dot Theophlline anhydrous, Theo-24 Prednisone, Prednisolone Generic SSRI/SNRI (Celexa, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL Albenza Droxia, Hydrea Crinone 8% Dovonex plus Diprolene/Diprosone; Taclonex Prograf capsules Depakene, Keppra XR, Onfi, Topamax Benzaclin, Benzamycin, Duac, Epiduo, OTC benzoyl peroxide plus Differin; RetinA, Tazorac Procrit, Retacrit Lamictal/ODT, Lithium, Trileptal, Tegretol/XR Lotrimin, Naftin, Nizoral, Spectazole Elidel, generic topical steroids, Protopic Alora, Climara, Estrace, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot Lotrimin, Naftin, Nizoral, Spectazole
Rilutek Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera Benzaclin, Benzamycin, Duac, Epiduo, Differin, Retin-A, Tazorac
Avelox, Erythromycin, Levaquin, Vibramycin, Zithromax Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa Alora, Climara, Estring, Estrogel, Minivelle, Vagifem, Vivelle-Dot
Tier 3
Preferred alternatives
FENORTHO
Generic NSAIDs [Celebrex, Lodine/XL, Mobic, Motrin (Rx only), Naprosyn (Rx only), Voltaren oral/XR, etc.]
FENTORA, FENTANYL BUCCAL TABLET (AUTHORIZED GENERIC OF FENTORA)
Actiq, MSIR, Opana IR, oxycodone IR, Roxanol
FETZIMA
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL
FINTEPLA
Depakote, Onfi, Topamax
FLAREX
Decadron ophthalmic, FML, Inflamase/Forte, Lotemax, Pred Forte, Pred Mild
FLECTOR PATCH, DICLOFENAC EPOLAMINE PATCH (AUTHORIZED GENERIC OF FLECTOR PATCH)
Generic NSAIDs [Celebrex, Lodine/XL, Mobic, Motrin (Rx only), Naprosyn (Rx only), Voltaren oral/XR, etc.], Lidoderm, OTC topical analgesic balms (i.e. trolamine salicylate); Voltaren gel
FLUOROPLEX
Aldara, Efudex, Tolak
FLUTICASONESALMETEROL RESPICLICK (AUTHORIZED GENERIC OF AIRDUO RESPICLICK)
Combination products: Advair Diskus/HFA, Breo Ellipta, Breztri Aerosphere, Dulera, Symbicort, Trelegy Ellipta Single ingredient products: Arnuity Ellipta, Asmanex/HFA, Flovent HFA/Diskus, Pulmicort Flexhaler/solution, Qvar Redihaler, Spiriva/Respimat, Serevent Diskus
FOLLISTIM AQ
Gonal-F/RFF/Redi-Ject
FOSAMAX PLUS D Actonel, Atelvia, Boniva, Fosamax plus OTC Vitamin D
FRAGMIN
Lovenox
FYCOMPA
Depakote/ER, Lamictal/ODT, Tegretol, Topamax, Trileptal
GALZIN
OTC zinc supplements
GELNIQUE
Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare
GONITRO
nitroglycerin, Nitrostat
GRALISE
Cymbalta, Generic TCA (Elavil, Sinequan, Tofranil, etc.), Lyrica, Neurontin, Ultram/ER
GRANIX
Nivestym, Zarxio
GRASTEK
Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal
GYNAZOLE-1
Diflucan 150mg, Monistat 3, Terazol
HARVONI
Epclusa (genotypes 5 and 6), Epclusa or Zepatier (genotypes 1 and 4)
HEMANGEOL
Inderal
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
HETLIOZ
HETLIOZ LQ HORIZANT
HUMATROPE ILEVRO IMVEXXY INBRIJA
INGREZZA INREBIC INSULIN LISPRO JUNIOR (AUTHORIZED GENERIC OF HUMALOG JUNIOR KWIKPEN) INTRAROSA INVELTYS
ISTURISA JATENZO
JORNAY PM
KARBINAL ER KATERZIA KERENDIA KEVEYIS KEVZARA KINERET
KLISYRI
Preferred alternatives
For Non-24 hour sleep-wake disorder: OTC melatonin, Ambien/CR, Lunesta, Restoril, Rozerem, Sinequan, Sonata For Nighttime sleep disturbances in SmithMagenis Syndrome (SMS): OTC melatonin, Rozerem, Sectral
OTC melatonin, Rozerem, Sectral
Generic TCA (Adapin, Elavil, Sinequan, Tofranil, etc.), Lyrica, Mirapex, Neurontin, Requip
Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin
Acular, Bromday, Ocufen, Voltaren ophthalmic
Estrace, Estring, Estrogel, Premarin, Vagifem
Azilect, Comtan, Eldepryl, Kynmobi, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar
Austedo
Jakafi
Fiasp (all forms), Novolin (NDCs ending in 00, 01, 11, and 15), Novolog (all forms)
Estring, Premarin, Vagifem
Decadron ophthalmic, FML, Inflamase/Forte, Lotemax, Pred Forte, Pred Mild
Dostinex, Lysodren, Nizoral, Signifor
Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Clarinex, Histex PD, OTC Claritin**, OTC Zyrtec**, Xyzal
Norvasc
Farxiga, Jardiance
Diamox
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz/XR
For rheumatoid arthritis: Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz/XR For recurrent pericarditis: ibuprofen, naproxen, colchicine
Aldara, Efudex, Tolak
Tier 3
Preferred alternatives
LAMPIT
benznidazole
LASTACAFT
Alrex, Bepreve, Elestat, Opticrom, Optivar, Pataday, Patanol
LATUDA
Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa
LIPOFEN, FENOFIBRATE 50MG, 150MG (AUTHORIZED GENERIC OF LIPOFEN)
Antara, Fenoglide, Lofibra, Lopid, Tricor, Trilipix
LIVALO
Crestor, Lescol/XL, Lipitor, Mevacor, Pravachol, Vytorin, Zocor
LO LOESTRIN FE Loseasonique, Mircette, Seasonique
LOMAIRA
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
LONHALA MAGNAIR Atrovent/HFA, Incruse Ellipta, Spiriva/Respimat
LOTEMAX SM
Decadron ophthalmic, FML, Inflamase/Forte, Lotemax, Pred Forte, Pred Mild
LUPANETA PACK
Lupron Depot 3.75mg, 11.25mg plus Aygestin
LUPKYNIS
Cellcept, cyclophosphamide, Imuran, Myfortic, Prograf
LUZU, LULICONAZOLE 1% CREAM (AUTHORIZED GENERIC OF LUZU)
Lotrimin, Naftin, Nizoral, Spectazole
LYBALVI
Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa
MARPLAN
Nardil, Parnate
MAVENCLAD
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
MAVYRET
Epclusa (genotypes 1-6), Zepatier (genotypes 1 and 4)
MAXIDEX
Decadron ophthalmic, FML, Inflamase/Forte, Lotemax, Pred Forte, Pred Mild
MENEST
Alora, Climara, Estrace, Vivelle-Dot
MENOSTAR
Alora, Climara, Estrace, Vivelle-Dot
METHITEST
Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred
MINITRAN
nitroglycerin, Nitrostat
MIRCERA
Procrit, Retacrit
MITIGARE, COLCHICINE CAPSULES (AUTHORIZED GENERIC OF MITIGARE)
Colcrys
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
Preferred alternatives
MOTEGRITY
Amitiza, lactulose solution, Linzess, OTC Miralax, OTC Senna, OTC Colace, OTC fiber
MOTOFEN
Imodium, Lomotil
MOVANTIK
Amitiza, lactulose solution, OTC Miralax, OTC Senna, OTC Colace
MOXATAG
Amoxil capsules
MYALEPT
Crestor, Insulin, Lescol/XL, Lipitor, Mevacor, Pravachol, Vytorin, Zocor
MYCAPSSA
Sandostatin, Somatuline Depot
MYFEMBREE
generic contraceptives (various), Lupron Depot 3.75mg, 11.25mg
MYRBETRIQ
Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare
NAMZARIC
Aricept/ODT, Exelon, Namenda/solution
NATAZIA
Mircette, Ortho Tri-Cyclen, Quartette, Yasmin, Yaz
NATESTO
Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred
NEBUSAL
generic sodium chloride inhalation
NEUPOGEN
Nivestym, Zarxio
NEUPRO
Lyrica, Mirapex/ER, Neurontin, Requip/XL
NEVANAC
Acular, Bromday, Ocufen, Voltaren ophthalmic
NEXTSTELLIS
Generic monophasic contraceptives (Beyaz, Loestrin, Nortrel, Ortho-Cyclen, Seasonale, Yaz, etc.)
NICOTROL, NS
OTC nicotine products (gum, lozenge, patch) (covered with Rx); Zyban
NOCDURNA
Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare
NOCTIVA
Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare
NORITATE
Finacea gel, Metrocream, Metrogel, Metrolotion
NOURIANZ
Azilect, Comtan, Eldepryl, Kynmobi, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar
NOVAREL
Pregnyl
NUCALA AUTO-
Advair, Dulera, Symbicort, Prednisone,
INJECTOR, SYRINGE Singulair, Accolate
NUCYNTA NUCYNTA ER NURTEC ODT
Dilaudid, MSIR, Opana IR, oxycodone IR, Ultram
Butrans, Duragesic, methadone, MS contin, Opana ER, Ultram ER, Zohydro ER
For migraine prevention: Depakote, Elavil, Inderal, Lopressor, Prozac, Topamax For acute migraine treatment: Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT
Tier 3
NUVESSA NUZYRA TABLET
NYMALIZE OBREDON ODACTRA
OLUMIANT
OMECLAMOX-PAK
OMNARIS
OMNITROPE
ONGENTYS
ONZETRA XSAIL
ORACEA, DOXYCYCLINE IRDR (AUTHORIZED GENERIC OF ORACEA) ORALAIR
ORAVIG
ORENCIA CLICKJET/SUBQ
ORGOVYX ORIAHNN
ORLADEYO OSMOPREP
OSPHENA OTREXUP
OXBRYTA OXTELLAR XR
Preferred alternatives
Cleocin vaginal cream, Metrogel-vaginal
Augmentin, Bactrim DS, Biaxin, erythromycin, Keflex, Monodox, Vibramycin, Vantin, Zithromax
Nimotop
Hycodan
Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Xeljanz, Xeljanz XR
Prevacid or Prilosec plus Amoxil plus Biaxin/XL
Astelin, Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase
Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin
Azilect, Comtan, Eldepryl, Kynmobi, Mirapex/ER, Requip/XL, Sinemet/CR, Tasmar
Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT
Finacea gel, Metrocream, Metrogel, Metrolotion, Minocin, Monodox, tetracycline, Vibramycin
Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal
Diflucan, Mycelex Troche, Nystatin, Sporanox
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Otezla, Rinvoq, Stelara, Taltz, Tremfya, Xeljanz/XR
Lupron
generic contraceptives (various), Lupron Depot 3.75mg, 11.25mg
Haegarda, Takhzyro
Colyte, Golytely, Moviprep, Nulytely, PegPrep
Estring or Vagifem plus a progestin
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Trexall, Xeljanz/XR
Droxia, Hydrea
Depakote/ER, Keppra/XR, Lamictal/ODT, Lyrica, Neurontin, Onfi, Tegretol/XR, Topamax, Trileptal
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
OXYCONTIN, OXYCODONE HCL ER (AUTHORIZED GENERIC OF OXYCONTIN) OZOBAX
PANCREAZE PAREMYD PERTZYE PEXEVA
PHOSLYRA PICATO PLENVU
POMALYST PONVORY
PRADAXA PRED-G PREFEST
PRESTALIA PREVYMIS TABLET PROCYSBI PROLENSA
PURIXAN QBRELIS QELBREE QNASL
QSYMIA
QUILLICHEW ER
QUILLIVANT XR
RAGWITEK
RASUVO
Preferred alternatives
Butrans, Duragesic, Exalgo, methadone, MS Contin, Opana ER, Ultram ER, Zohydro ER
Baclofen, Flexeril, Norflex, Parafon Forte DSC, Robaxin, Zanaflex
Creon, Viokace, Zenpep
Cyclogyl, Isopto Atropine plus Mydriacyl
Creon, Viokace, Zenpep
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL
Phoslo, Renagel, Renvela
Aldara, Efudex, Tolak
Colyte, Golytely, Moviprep, Nulytely, PegPrep
Thalomid
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
Eliquis, Warfarin, Xarelto
Garamycin plus Pred Forte
Activella, Alora, Climara, Fem-HRT, Premphase, Prempro, Vivelle-Dot
Aceon plus Norvasc, Lotrel
Valcyte
Cystagon
Acular, Bromday, Ocufen, Voltaren ophthalmic
mercaptopurine tablets
Prinivil, Zestril
Intuniv, Kapvay, Strattera
Astelin, Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
Accolate, Clarinex, Flonase, Nasalide, Nasonex, OTC Claritin**, OTC Nasacort, OTC Zyrtec**, Singulair, Xyzal
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Trexall, Xeljanz/XR
Tier 3
Preferred alternatives
RAVICTI
Buphenyl
RAYALDEE
Calciferol, Hectorol, Rocaltrol, Zemplar
RAYOS
cortisone, Decadron, Medrol, prednisolone, prednisone
RECTIV
Nitro-Bid ointment
REDITREX
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Rinvoq, Trexall, Xeljanz/XR
RELEXXI, METHYLPHENIDATE ER 72MG
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Ritalin LA/SR *can be opened and sprinkled on applesauce
RELISTOR TABLETS Amitiza, lactulose solution, OTC Miralax, OTC Senna, OTC Colace
REVLIMID
Thalomid
REXULTI
Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa
REYVOW
Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT
RIOMET ER
Glucophage/XR, Riomet
RYTARY
Parcopa, Sinemet/CR
SAIZEN, SAIZENPREP
Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin
SANCUSO
Kytril, Zofran/ODT
SAVAYSA
Eliquis, Warfarin, Xarelto
SAVELLA
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), generic TCA (Aventyl, Elavil, Sinequan, Tofranil, etc.), Flexeril, Neurontin, Ultram
SAXENDA
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
SECUADO
Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa
SIGNIFOR LAR
Sandostatin LAR Depot, Somatuline Depot, Somavert
SIKLOS
Droxia, Hydrea
SILIQ
Enbrel, Humira, methotrexate, Otezla, Skyrizi, Stelara, Taltz, Tremfya
SIMBRINZA
Alphagan plus Azopt
SIMPONI
Actemra Actpen/syringe, Enbrel, Humira, methotrexate, Otezla, Rinvoq, Stelara, Taltz, Xeljanz/XR
SITAVIG
Famvir, Valtrex, Zovirax
SLYND
Ortho Micronor, Nor-QD
SOLTAMOX
tamoxifen
SORILUX, CALCIPOTRIENE FOAM (AUTHORIZED GENERIC OF SORILUX)
Dovonex
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
SOTYLIZE SOVALDI SPRITAM STENDRA STRIVERDI RESPIMAT SUBSYS SUNOSI
SUPREP SUTAB SYMLINPEN
SYMPAZAN SYMPROIC SYNAREL
SYNDROS TALICIA
TAVALISSE TEKTURNA HCT
TEXACORT
TIGLUTIK TIROSINT, LEVOTHYROXINE CAPSULE (AUTHORIZED GENERIC OF TIROSINT), TIROSINT-SOL
Preferred alternatives
Betapace, Cordarone, Multaq, Tikosyn
Epclusa or Zepatier (genotypes 1 and 4), Epclusa (genotypes 2-3)
Depakote/ER, Keppra/XR, Lamictal/ODT, Tegretol, Topamax, Trileptal
Cialis, Levitra, Staxyn, Viagra
Serevent Diskus, Spiriva/Respimat
Actiq, MSIR, Opana IR, oxycodone IR, Roxanol
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Nuvigil, Provigil, Ritalin LA/SR *can be opened and sprinkled on applesauce
Colyte, Golytely, Moviprep, Nulytely, PegPrep
Colyte, Golytely, Moviprep, Nulytely, PegPrep
Actos, Glucophage, Insulin, Precose, a DPP-4 inhibitor (Januvia, Tradjenta), an SGLT-2 inhibitor (Farxiga, Invokana, Invokamet, Jardiance), a sulfonylurea (Amaryl, Glucotrol/XL, Glynase)
Onfi, Topamax
Amitiza, lactulose solution, Linzess, OTC Miralax, OTC Senna, OTC Colace
For endometriosis: generic contraceptives (various), Lupron Depot 3.75mg, 11.25mg For central precocious puberty: Lupron Depot-PED
Compazine, Kytril, Marinol, Megace, Phenergan, Reglan, Zofran/ODT
Prevacid plus Amoxil plus Biaxin/XL; tetracycline plus Flagyl plus OTC bismuth subsalicylate; Prilosec plus Amoxil plus Biaxin/XL
Promacta
Tekturna plus hydrochlorothiazide, Generic ACE inhibitor (Lotensin, Zestril, etc.) or generic ARB (Atacand/HCT, Avalide, Avapro, Benicar/HCT, Cozaar, Exforge, Hyzaar, Teveten)
Aclovate, Dermacort, Derma-Smoothe, Desowen, Synalar solution, Valisone cream/lotion
Rilutek
Synthroid
Tier 3
TIVORBEX, INDOMETHACIN 20MG (AUTHORIZED GENERIC OF TIVOBEX 20MG) TOBI PODHALER TOBRADEX ST TOVIAZ
TRINTELLIX
TROKENDI XR
TUDORZA PRESSAIR TUXARIN ER
TUZISTRA XR
TYBLUME
UBRELVY
UCERIS FOAM
ULESFIA VALCHLOR VARUBI TABLET VECAMYL VELPHORO VERDESO
VEREGEN VERQUVO VERSACLOZ VESICARE LS VIBERZI
VIIBRYD, DOSEPAK
Preferred alternatives
Generic NSAIDs [Celebrex, Indocin, Lodine/XL, Mobic, Motrin (Rx only), Naprosyn(Rx only), Voltaren oral/XR, etc.]
Tobi
Tobradex suspension/ointment, Vasocidin
Detrol/LA, Ditropan/XL, Enablex, Sanctura/XR, Vesicare
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL
For seizure disorder: Depakene, Depakote, Keppra/XR, Klonopin, Topamax, Trileptal For migraine prevention: Elavil, Depakote, Inderal, Toprol, Topamax
Atrovent/HFA, Incruse Ellipta, Spiriva/Respimat
Hycodan, Phenergan w/codeine, Tussionex
Hycodan, Phenergan w/codeine, Tussionex
Generic monophasic contraceptives (Beyaz, Loestrin, Nortrel, Ortho-Cyclen, Seasonale, Yaz, etc.)
Amerge, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, Zomig/ZMT
Canasa, Cortenema, Proctocort suppository, Proctosol-HC suppository, Rowasa, SfRowasa
Elimite, Lindane, Natroba, Ovide
8-Mop, Zolinza
Emend, Kytril, Zofran/ODT
Catapres, Cozaar, Toprol XL, Zestril
OTC Tums, Phoslo, Renagel, Renvela
Aclovate, Dermacort, Derma-Smoothe, Desowen, Synalar solution, Valisone cream/lotion
Condylox solution/gel
Entresto
Clozaril, Fazaclo
Ditropan/XL
Bentyl, Imodium, Levbid, Levsin, generic SSRI (Celexa, Prozac, Zoloft, etc.), generic TCA (Adapin, Elavil, Sinequan, Tofranil, etc.)
Generic SSRI/SNRI (Celexa, Cymbalta, Effexor/XR, Pristiq, Prozac, Zoloft, etc.), Wellbutrin/SR/XL
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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Tier 3
VOGELXO, TESTOSTERONE 1% (AUTHORIZED GENERIC OF VOGELXO) VOSEVI VRAYLAR VUMERITY VUSION, MICONAZOLE/ZINC OXIDE (AUTHORIZED GENERIC OF VUSION) VYZULTA WAKIX
WEGOVY WINLEVI XADAGO XATMEP XCOPRI XELPROS XENICAL XEPI XIFAXAN 200MG XIFAXAN 550MG
XOFLUZA XOLAIR SYRINGE
XOLEGEL
Preferred alternatives
Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred
Epclusa or Zepatier (genotypes 1 and 4), Epclusa (genotypes 2-3, 5-6)
Abilify, Clozaril, Geodon, Invega, Risperdal, Seroquel/XR, Zyprexa
Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera
generic topical antifungal (such as nystatin or Nizoral) plus OTC topical zinc oxide ("A&D" ointment)
Lumigan, Travatan Z, Xalatan
Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Nuvigil, Provigil, Ritalin LA/SR *can be opened and sprinkled on applesauce
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
Benzaclin, Benzamycin, Differin, Minocin, Monodox, Retin-A, Tazorac, Vibramycin
Azilect, Eldepryl
Methotrexate, Trexall
Dilantin, Keppra/XR, Lamictal/ODT, Lyrica, Tegretol, Topamax, Trileptal, Vimpat
Xalatan, Lumigan, Travatan Z
Adipex-P, Bontril, Didrex, OTC Alli, Tenuate
Bactroban ointment, gentamicin cream/ointment
Bactrim DS, Vibramycin, Zithromax
For IBS-D: Bentyl, Imodium, Levbid, Levsin, generic SSRI (Celexa, Paxil, Zoloft, etc.), generic TCA (Elavil, Sinequan, Tofranil, etc.) For hepatic encephalopathy: lactulose solution
Tamiflu
For asthma: Advair, Dulera, Symbicort, Prednisone, Singulair, Accolate For chronic idiopathic urticaria: Clarinex, Atarax, Doxepin, Singulair, Accolate For nasal polyps: Flonase; Nasalide, Nasonex, OTC, Nasacort, OTC Rhinocort
Lotrimin, Naftin, Nizoral, Spectazole
Tier 3
XOPENEX HFA, LEVALBUTEROL TARTRATE HFA (AUTHORIZED GENERIC OF XOPENEX HFA) XYOSTED
XYREM
XYWAV
YUPELRI
ZEGALOGUE
ZELAPAR ZELNORM
ZEMBRACE SYMTOUCH ZEPOSIA
ZETONNA
ZIOPTAN ZIPSOR
ZOMACTON
ZOMIG NASAL SPRAY, ZOLMITRIPTAN NASAL SPRAY (AUTHORIZED GENERIC OF ZOMIG) ZONTIVITY
Preferred alternatives
Proair HFA, Proventil HFA, Xopenex nebulizer solution
Androderm, Androgel, Android, Axiron, Delatestryl, Depo-Testosterone, Testim, Testred Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Nuvigil, Provigil, Ritalin LA/SR *can be opened and sprinkled on applesauce Adderall/XR* (brand BCN only), Aptensio XR, Concerta, Focalin/XR*, Metadate CD*, Methylin, Nuvigil, Provigil, Ritalin LA/SR *can be opened and sprinkled on applesauce Atrovent/HFA, Incruse Ellipta, Spiriva/Respimat Baqsimi, Glucagen emergency kit/Hypokit, Gvoke Azilect, Eldepryl Amitiza, lactulose solution, Linzess, OTC Miralax, OTC Senna, OTC Colace, OTC fiber Amerge, Axert, Frova, Imitrex injection, Maxalt/MLT, Relpax, Zomig/ZMT
For multiple sclerosis: Avonex, Copaxone, Gilenya, Kesimpta, Mayzent, Plegridy, Rebif, Tecfidera For ulcerative colitis: prednisone, budesonide, cyclosporine, azathioprine Astelin, Flonase, Nasalide, Nasonex, OTC Nasacort, OTC Rhinocort, Patanase Lumigan, Travatan Z, Xalatan Generic NSAIDs [Celebrex, Lodine/XL, Mobic, Motrin (Rx only), Naprosyn (Rx only), Voltaren oral/XR, etc.] Genotropin, Norditropin Flexpro, Nutropin AQ NuSpin Amerge, Axert, Frova, Imitrex nasal spray, Maxalt/MLT, Relpax, Zomig/ZMT
Aggrenox, Brilinta, Effient, Plavix, Persantine plus OTC Aspirin
** May be covered with a prescription for some Blue Cross members.
NOTE: This document serves as a quick reference guide. For the most current list of covered medications and requirements, visit pharmacy.
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